2012-2012 RW Part B MOA Attachment III Services and Fees
DENTAL 2012- 2012
DESCRIPTION
FEE
Periodic Oral Evaluation
Comprehensive Oral Eval-New or Established
Emergency Oral Evaluation
Intraoral – Complete X-Rays, Including Bitewing (1 annually)
Intraoral – Periapical, 1st Film
Periapical Film, Each Additional Film
Bite-wings, 2 Films
Bite-wings, 4 Films
Panoramic Film (one annually)
Prophylaxis – Adult (twice annually)
$35.00
$46.00
$46.00
$75.00
$15.00
$15.00
$25.00
$37.00
$67.00
$60.00
Amalgam – 1 Surface, Permanent
Amalgam – 2 Surfaces, Permanent
Amalgam – 3 Surfaces, Permanent
Amalgam – 4+ Surfaces, Permanent
Resin – 1 Surface, Anterior
Resin – 2 Surfaces, Anterior
Resin – 3 Surfaces, Anterior
Resin - 4+ Surfaces or Involving Incisal Angle (Anterior)
$73.00
$89.00
$104.00
$120.00
$85.00
$103.00
$125.00
$155.00
Complete Denture – Maxillary
Complete Denture – Mandibular
Upper Partial-Resign Base
Low Partial-Resign Base
Maxillary Partial Denture
Mandibular Partial Denture
Adjust Complete Denture-Maxillary
Adjust Complete Denture-Mandibular
Adjust Partial Denture-Mandibular-replace broken teeth -Per tooth
Add tooth to existing Partial Denture
Add Clasp to Existing Partial
$785.00
$785.00
$500.00
$500.00
$875.00
$875.00
$85.00
$75.00
$75.00
$86.00
$105.00
Periodontal Scalling and Root Planing - four or more teeth
Periodontal Scalling and Root Planing - one to three teeth
Debridement
Extraction, Erupted Tooth or Exposed Root
Surgical Removal of Erupted Tooth Requiring Elevation of
Mucoperiosteal Flap and Removal of Bone and/or Section of Tooth
Removal of Empacted Tooth-Soft Tissue
Removal of Impacted Tooth – Partially Bony
Removal of Impacted Tooth – Completely Bony
Surgical Removal of Residual Tooth Roots (Cutting Procedure)
Palliative (Emergency) Treatment of Dental Pain-M
-Minor
$150.00
$100.00
$85.00
$80.00
$145.00
CODE
Diagnostic and Preventative
D0120
D0150
D0140
D0210
D0220
D0230
D0272
D0274
D0330
D1110
Restorative
D2140
D2150
D2160
D2161
D2330
D2331
D2332
D2335
Prosthodontics
D5110
D5120
D5211
D5212
D5213
D5214
D5410
D5411
D5640
D5650
D5660
Oral Surgery & Periodontics
D4341
D4342
D4355
D7140
D7210
D7220
D7230
D7240
D7250
D9110
$172.00
$205.00
$255.00
$155.00
$45.00
Any Service not listed will be paid at Medicaid rates and MUST be pre-approved.
RWII is the payer of last resort. Clients who have coverage or are eligible for Medicaid, Medicare (A,B,D), Private
Insurance or other coverage do not access RWII unless exceptions have been made (i.e. eligibility and coverage
are pending approval).
Updated 3/14/12